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Clinical Impact and Value of Workstation Single Sign-On
Session 30, February 12, 2019
George A. Gellert, MD, MPH, MPA and John F. Crouch, CHRISTUS Health
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George A. Gellert, MD, MPH, MPA
Has no real or apparent conflicts of interest to report.
John F. Crouch
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Learning Objectives
• Background
• Methods
• Results
– Financial Analysis
– Other
• Conclusions
• Questions
Agenda
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• Learning Objective 1: Identify the overall clinical, operational, and
financial value proposition of workstation single sign on (SSO)
• Learning Objective 2: Recognize the nature and magnitude of the impact
of SSO on clinician login time by comparing pre-SSO to post-SSO
implementation times across 6 hospitals evaluated
• Learning Objective 3: Recognize the qualitative impact of SSO on
clinician satisfaction and how SSO is facilitating adoption of other clinical
information technology such as digital documentation
• Learning Objective 4: Evaluate the results of cost effectiveness and
return on investment analyses completed on SSO implementation
• Learning Objective 5: Analyze the methodology utilized to evaluate and
quantify the impact of SSO
Learning Objectives
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• Providers adopting EHRs must maintain the security of
protected health information and HIPAA compliance
• What makes passwords effective – complexity and
frequent change – also makes them difficult to remember
• Clinicians often must recall and regularly refresh 8-20+
passwords
Background
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• Time lost by clinicians entering multiple passwords and
resetting them when forgotten diverts from patient care
• Single Sign-On (SSO) facilitates clinicians’ use of EHR
technology, including CPOE and digital documentation
• SSO objectives: Provide clinicians expedited access to
EHR and clinical applications; eliminate password
confusion and time wasted in password management;
enhance HIPAA compliance via authentication
Background
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• With SSO, once logged in, clinicians need only tap or swipe
enabled identification proximity badge on workstation card
readers (except those reserved for downtime access)
• Across hospital, proximity badge to “tap and go” enables users
to pick up exactly where they left off -- conveys rapid access to
EHR and other functionality as they change location
• When the clinician changes workstation, a tap on the badge
reader brings the most recent screen used to the new screen
Background
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• SSO automatically locks workstations when care
providers leave and re-authenticates when they return to
where they left off
• Eliminates need to manually lock sessions or use
(sometimes unreliable) inactivity timers, and prevents loss
of work
• SSO reduces repetitive, manual logins with automated
process
Background
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• Expedites authenticated access to clinical applications
used during a 12 hour shift, after which usual login must
be repeated to enable another cycle
• SSO provides support for all types of applications
including terminal, client server and cloud-based
applications
• Password administration enables automated application
password change, eliminating this task for clinicians
Background
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• Quantitative evaluation of SSO impact in 19 CHRISTUS Health
hospitals. CH is a mid-size IDN in 6 U.S. states; > 350 services,
49 hospitals, 15,000+ physicians
• EHR – MEDITECH Client Server Version 5.66
• SSO product – Imprivata OneSign Version 5.1
• Reports on clinician SSO use: # deployed users; # active
users; # logins; frequency of app access; average logins/user;
average application events/user
Methods
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• Required migration from workstation PCs to a thin client
and Cloud processing
• Migrated to a virtual desktop infrastructure (VDI) to enable
clinician roaming across service lines
• 45 clinical software applications profiled and enabled
• SSO provided to MDs, RNs, mid-levels and roaming
ancillary (RTs, PTs and dieticians)
Methods
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• 7 day observation period of SSO usage in April 2018
• Measured mean login duration to workstations pre-SSO
and compared to post-SSO implementation
• Post-SSO involved 2 logins: 1st login of day to desktop
and subsequent EHR reconnects/re-logins using card
reader/swipe technology
• Mean login durations were multiplied by total number of
initial and subsequent logins
Methods
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• Assessed total time required for clinicians to login pre-
and post-SSO and quantify benefit from decreased
clinician login times
• Utilized national median hourly pay rates to translate
hourly/shift time savings into dollar cost value of
clinician time liberated from keyboard for 3 clinical
groups (MDs, RNs and Ancillary)
• Estimated cost savings by replacing PC hard drives
($900 per unit) with thin client (WYSE) devices ($200
per unit)
Methods
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Login Parameter Frequency
Active clinical users of Single Sign
-On (19 hospitals)
12,903
Total Number of Logins to EHR over 7 days
184,606
Total Number of First of Shift Logins to EHR over 7 days
24,472
Total Number of Reconnect/Re
-Logins to EHR over 7 days
160,134
Results
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SSO
Implementation
Phase
First of Shift
Login Time
Reconnect Time
Rest of Shift
Time Reduction Per
Login (%
Improvement)
Pre
-SSO
Implementation
34.6 seconds 29.3 seconds --
Post
-SSO
Implementation
29.3 seconds 8.9 seconds
First login: 5.3 seconds
(15.3%)
Re
-login: 20.4 seconds (69.6%)
Results
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Login Performance Parameter Frequency or Time
Keyboard Time
Reduction
Time Duration
First of Shift Logins 7 days:
Pre
-SSO
Post
-SSO
235.2 hours
[19.6 shift equivalents*]
199.2 hours
[16.6 shifts]
36.0 hours
[3.0 shifts]
Time Duration
Reconnect Logins 7 days:
Pre
-SSO
Post
-SSO
1303.3 hours
[108.6 shifts]
395.9
[33.0 shifts]
907.4 hours
[75.6 shifts]
Results
*[Shifts equivalents = shifts of 12 hours]
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Login Performance Parameter
Number of
Facilities
Keyboard Time
Reduction
Total Enterprise WEEKLY time savings
enabled
by SSO
Total Per Facility WEEKLY time savings
enabled
by SSO
19 hospitals
1 hospital
943.4 Hours [78.6 shifts]
49.7 hours [4.1 shifts]
Total Enterprise ANNUAL time savings
enabled
by SSO
Total Per Facility ANNUAL time savings
enabled
by SSO
19 hospitals
1 hospital
49,056 hours [4088.1 shifts]
2584.4 hours [215.4 shifts]
Results
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• Calculated the dollar cost savings of time for 3 clinician
categories – MDs, RNs ancillary personnel (PTs,
dieticians and RTs)
• 30% of clinical users were MDs, 57% were RNs, and 13%
ancillary
• For RNs, used national average wage of $34.50 per hour
• Collapsed PTs, dieticians and RTs into a single category
with averaged hourly wage of $32.20 per hour
Results – Financial Analysis
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• Estimating MD hourly wages is complex because income
varies considerably across specialties
• Divided MDs into 4 groups of highest EHR users issuing
greatest volume of orders thru CPOE: hospitalists;
emergency medicine physicians; general surgeons; all
other MDs collapsed
• Estimated that each group = 25% of EHR/applications
use, and thus SSO use
Results – Financial Analysis
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• Used multiple MD specialty wage estimates: U.S. Dept.
Labor, Becker’s Hospital Review 2015, Salary.com,
Medscape Physician Compensation Report 2016
• Yielded hourly mean wage of $108 for hospitalists, $144
for emergency medicine physicians and $170 for general
surgeons
• Averaging hourly wage of the 4 categories yielded a
generic physician hourly wage of $138 -- quite
conservative estimate
Results – Financial Analysis
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Results – Financial Analysis
Professional
Category
Percentage of All
SSO Users
[Annual Hours
Liberated 19
Facilities]
Estimated
Hourly Wage
Annual Value of
Liberated
Time/Cost
Savings Per
Facility
Annual Value of
Liberated
Time/Cost
Savings 19
Facilities
Physicians
(Hospitalists, Emergency
Medicine Physicians, Surgeons
and all others)
14,717.0 hours
[30%]
$138.00 $106,892 $2,030,946
Nurses
27,962.4 hours [57%] $34.50 $50,744 $964,703
Ancillary
(PTs, RTs &
Dieticians)
6,377.4 hours
[13%]
$32.20 $10,808 $205,352
All Professional Categories
100% -- $168,474 $3,201,001
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• Migration to WYSE devices achieved savings in averted
new replacement PC purchases – unit cost of $200 vs.
$900 = $700 savings per device
• 2432 WYSE devices deployed = $3,404,800 savings over
next 8 fiscal years or $425,600 savings per year
Results – Financial Analysis
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• Enterprise total SSO implementation cost was $1.23
million
• Annual maintenance cost for SSO is $296,000
• With value rendered by SSO in clinician shifts at
$3,201,001 per annum, adjusting for equipment costs, the
NET TOTAL ANNUAL recurrent value is $3,330,601
across 19 facilities
• SSO delivers substantial recurrent annual ROI, value and
net cost savings to our hospital system
Results – Financial Analysis
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Expenditure Savings Financial Costs Financial Value/Return
Net implementation cost of SSO
Annual maintenance cost
of SSO
$1,230,000
$296,000
--
--
Averted annual purchase of replacement desktop PCs
-- $425,6000
Clinician time and shift equivalents liberated from the keyboard per
year
Total net annual savings or value rendered by SSO implementation
across 19 facilities
--
--
$3,201.001
$3,330,601**
Results – Financial Analysis
**Averted PC purchases + clinician liberated time value – annual SSO maintenance cost
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• Clinicians reported high SSO satisfaction with the
improved ease/speed of access to clinical workstations
and applications
• SSO can facilitate EHR adoption, particularly among
physicians
• Our implementation of digital documentation overlapped
with SSO, and physicians reported that SSO enabled
their adoption of digital documentation and made CPOE
use easier
Results – Other
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• SSO had a significant favorable impact on clinician
efficiency and productivity in these 19 hospitals
• SSO is an effective and highly cost-effective method
to liberate clinician time from repetitive, time consuming
logins to clinical applications
• SSO can facilitate adoption of key component EHR
functionalities and applications
Conclusions
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• May need to update/upgrade other components of IT
infrastructure, such as replacing PCs with thin clients,
cloud processing and VDI
• This reduces need for costly PC replacement and
upgrades, and produces substantial hardware
expenditure savings
• SSO has been a strong “clinician satisfier” - clinicians
report SSO enabled them to focus attention on patient
care rather than EHR/IT
Conclusions
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• While not “game changing” in overall impact on clinician
time demanded by EHR/IT, SSO offers an incremental
real, meaningful liberation of clinician time and
improvement in clinical workflow
• SSO implementation is recommended in hospitals where
multidisciplinary clinician use of EHRs and related
technology is substantial, and where clinical workflow
involves substantial facility roaming
Conclusions
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• SSO can save time, improve security and increase
clinician efficiency and satisfaction in today’s complex
healthcare organizational workflows
Conclusions
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• Thanks for your attention. For further information, please
contact: ggellert33@gmail.com
• Please remember to complete the online session evaluation
Questions
